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-FOR OFFICE USE: <br /> ---------- <br /> ... -------- <br />------ ----- ---------—------------------------------ APPLICATION FOR` SANITATION PERMIT Permit <br /> A <br /> --------------------------------------------------- (Complete in Duplicate) Date Issued <br />-------------------------------------------- This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and -install the work herein described. <br /> This.application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION 4 2,-3 -3 i�� IRV. <br /> *1 - - -----------4------------------------------------------------------------------------------------------------------------------------ -------- <br /> Owner's Name--------- ----------- ------------a----------- -------- -------------------------------------------.__ Phone------------------------------------ <br /> Address------------ <br /> ----------------------I----------------------------------------------------------------------------------------------------------------------------- -----------­---------------- <br /> Con',fractor's - ---4T <br /> -- ----------------I—-------------------------------------------- Phone------------------......--------- <br /> Installation will serve: Residence E] Apartment House E] Commercial Y]_�Trailer Court E] Motel El Other ❑ <br /> Number of living units: -------- Number of bedrooms -------- Number of baths _Z--- Lot size ...... --------------------------------- <br /> Water Supply: Public 'system El Community system F-I Private P-T&pth to Water Table -4-oft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loom El Clay Loam 0 Clay E] Adobe[1-1arclpan F1 <br /> Previous Application Made: (if yes,date--------------------) No WR'-'New Construction: Yes El No Zi" FHANA: Yes E] No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septle-1, Distance from nearest well-----------------Distance from foundation______---_-_-_____-Material__-______-_-____----_..-____---.------.._...-_--. <br /> No. <br /> aterial----------- -------- --------------------------- <br /> No. of corr`partmenfs------------- - --0.1-----Size-------------------------------Liquid depth----------------- -------Capacity---------------- <br /> Dis Distance from nearest well/AX_��t -Distance from foundation-_-lk...........Distance to nearest lot <br /> I - - ------------- <br /> T ------ <br /> Number of lines----__.1_ -___--_-Length of each line_..30-'7_-----f--------Width of trench_ _tl - _.e of filter maferiar,�? 'it ­ -- --------------------- <br /> Type I----A-0 ce%A_-____Depth of filter material--_- --S-----------..Total length------ <br /> Seepage Pit: Distance to nearest well-/001----------Distance f om foundation-_6?-----------D-,tance to nearest lot line----------------- 2C I <br /> Number of pits-----{---------------Lining material.- AC-Size: Diameter----!_x___,- <br /> ......Depth---- --------------- <br /> Ces§'pool-. k r Distance from nearest well-------------- --Distance from founclation---------------------Lining material_-----_.-----_-----------___-__-. d"', <br /> El Size: Diameter----- ---- --------Z-1----------------Depth------------------------- --- ------------ --------Liquid Capacity----------- ------ ---------gals. <br /> Priv' : Distance from nearest well_____--_--------_----- ..---_-.._.-Distance from nearest buildin❑ g------------------------------------------ d i <br /> Distanceto nearest lot line------------------------------------------------ ----------------------------- -------------------------------- ------------------ r <br /> Remodeling and/or repairing (describe):------------------------- ---------------------------------------------------------------------- -------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----- <br /> ----------------------------- ----------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - -------------------------------------- ------------------------------------------------------------------- -------------------------------------------------------------------------------------- --------------- ------------- <br /> I hereby certify that I have prepared'Ais application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules anijopegulations of the San Joaquin Local Health District. <br /> (Signed)------------------------------------ - ------------------------------------------ ---------------------(Owner and/or Contractor) <br /> By:------------------------------------------------------------------------------ ------ ----------------------------------------------(Title)- ----- ---------------------- <br /> (Plot <br /> (Title)---------------------------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--kk7M1_ ------------------------------------------------------- DATE---- ---------------------------------- <br /> REVIEWEDBY-------------------------------------- ---------------------------------------- ------- -------------------------------------- DATE---------------------------------------------------------- - <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------ --------- DATE------ -------------- ------------------- ------------------ <br /> Alterationsand/or recommendations:-------- --------- -------A - ----------------------------------- --------------------------------------------------------------------------- <br /> ----- --- --------- -------- -- -------------------------------- <br /> ----------- <br /> ------------ -IVI--------;--r----------- --- --------- ----------------------------- - ---- - <br /> ----------------------- ---- ------------------------- -------------------- ---------------------------------------------------------------------------------------------- <br /> -----------I----------------------------------- ------- ---- ----- ------ ---------------------------------- -------- - -------- ---------------------------------------------------------- ----------------- <br /> - ---- - ------ <br /> -------------------------------------- .. ........... -- -- -- - ------------------------ --------- -------------------------------------- ------------------------- - -- -------- ---------------- <br /> FINAL INSPECTION BY:..'---.!! -- ---------- - Date-------- / --------------- ------ ---------------------- <br /> S JUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California ManteCOr California Tracy,California <br /> F.RCU. <br />